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Dysfunctional Labor may occur because of abnormalities in the powers, the passanger, the passage or the psyche. Combinations of abnormalities are common
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Nursing care in dysfunctional labor focuses on prevention or prompt identification and action to correct additional complications: Fetal hypoxia, infection, injury to the mother or fetus, and postpartum hemorrhage.
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PROM is associated with infection as both a cause and an effect.
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The early indications of PTL are often vague. Prompt identificatin of PTL enable the most effective therapy to delay preterm birth
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Nursing care for the woman at risk for a very early preterm birth focuses on helping her delay birth long enough to promote fetal lung maturation with corticosteroids, allow transfer to a faclitiy with an appropriate level of neonatal intensive care, or reach a gestation at which teh infants problems with the immaturity are minimal.
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The main risk in prolonged pregnancy is reduced placental function. THis may compromise the fetus during labor and may result in meconium aspiration in the neonate. Dysfunctional labor may occur as a fetus continues growing during the prolonged pregnancy.
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THe key intervention of umbilical cord prolapse is to relieve pressure on the cord without compressing its blood vessels and to expedite delivery.
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Be aware of women at risk for uterine rupture and observe for signs and symptoms: signs of shock abdominal pain a sense of tearing chest pain, pain in the shoulder area, abnormal FHR patterns, cessation of contractions and palpation of the fetus outside the uterus.
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Uterine inversion is often accompanied by massive blood loss and shock. Recovery care promotes uterine contraction and maintenance of adequate circulating volume.
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Anaphylactoid syndrome is more likely to occur when labor contractions are intense, allowing particulate matter to be forced into the mothers circulation. Once thought to result only from amniotic fluid entering the maternal circulation this critical complication has also been associated with other complications such as maternal sepsis, preeclampsia and cardiac disease.
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Automobile accidents are the major cause of blunt force trauma and may result in premature separation of the placenta, hemorrhage, fractures and internal injuries. Penetrating injuries cause by knives or bullets are particularly dangerous for the fetus
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The treatment of trauma during pregnancy is similar to that in a nonpregnant person. Providing cardiopulmonary support and controlling bleeding are teh priorites. Careful evaluation of the uterus and fetus is also essential.
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Premature separation of a normally implanted placenta
Abruptio placentae
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Excessive volume of amniotic fluid
Hydramnios
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Placenta that is abnormally adherent to the uterine muscle
Placenta accreta
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Delayed or difficult birth of the shoulders after the head has emerged
Shoulder dystocia
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Medication to stop preterm or hypertonic labor contractions
Tocolytic
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What are three characteristics of effective uterine activity?
Uterine contractions must be coordinated, strong enough and numerous enough to propel the fetus through the womans pelvis.
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What two measures may be used to stimulate labor that slows down after it is established.
Amniotomy
oxytocin augmentation
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What is the central principal of nursing actions when dysfunctional labor is a result of ineffective maternal pushing?
All nursing actions center on helping the woman make each push most effective
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Why are upright positions good for women who have ineffective 2nd stage pushing?
They add the force of gravity to maternal pushes.
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List nursing measures to promote normal labor when maternal pushing is ineffective for reason listed?
Fear of injury
Help the woman understand that her tissues can distend to accommodate the fetus apply warm compresses to the perineum
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List nursing measures to promote normal labor when maternal pushing is ineffective for reason listed?
Exhaustion
- Teach the woman to push only when she feels the urge or with every other contraction
- administer fluids as ordered
- offer reassurance
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Why are upright maternal positions best to relieve persistent occiput posterior positions?
Upright positions favor fetal descent (gravity) and with that descent fetal head rotation
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List four intrapartal problems that are more likely if a woman has multifetal pregnancy?
Uterine overdistention with hypotonic dysfunction
abnormal fetal presentation(s)
fetal hypoxia
postpartum hemorrhage resulting from uterine overdistention
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What are the expected rates for dilation and fetal descent for the following?
Nulliparas
Dilation at least 1.2cm/hr
descent at least 1.0cm/hr
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What are the expected rates for dilation and fetal descent for the following?
Parous women
Dilation at least 1.5cm/hr
descent at least 2.0cm/hr
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List nursing measures for women having prolonged labor and for her fetus
For mother: promotion of comfort, conservation of energy, emotional support, position changes that favor normal progress and assessments for infection
For the fetus observation for signs of intruteine infection and for compromised fetal oxygenation.
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List nursing measures that may be used when a woman has precipitate labor.
Promoting fetal oxygenation
- Place her in a side lying position administer oxygen maintain blood volume with nonoxytocin IV
- stop oxytocin if in use administer terbutaline or other tocolytic drug that may be ordered.
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List nursing measures that may be used when a woman has precipitate labor.
Promoting maternal comfort
Help woman focus on non-pharmacologic pain control methods if analgesia is not possible remain with the woman
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What factors may make a woman think her membranes have ruptured when they have not?
Urinary incontinece
increased vaginal discharge
loss of mucous plug
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A patient will be discharged with ruptured membranes at 32 weeks of gestation. Write summary of patient teaching in a simple terms taht you might use?
Points to include are avoid sexual activity
take temperature four times a day and report if higher that 100.0 (37.8)
report contractions
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List side effects that may occur with beta-adrenergic drugs such as terbutaline. What drug should be available to reverse serious adverse serious adverse effects of beta-adrenergic drugs and what is its classification.
Side effects of beta-adrenergic drugs include maternal and fetal tachycardia, decreased blood pressure, wide pulse pressure, dysrhythmias, myocardial ischemia, chest pain, pulmonary edema, hyperglycemia and hypokalemia, tremors and restlessness.
Propranolol (Inderal, a beta-blocking drug should be available to reverse the effects.
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How does this drug stop pretem labor? give and example?
Protaglandin synthesis inhibitors
Prostaglandin synthesis inhibitors block the action of prostaglandins which stimulate uterine contraction and example is (indomethacin)
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How does this drug stop pretem labor? give and example?
Calcium antagonists
Calcium antagonists block the action of calcium, which is necessary for muscle contraction: an example i (nifedipine)
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What is the primary nursing assessment related to this tocolytic drugs
Terbutaline
Observe maternal blood pressure pulse and respirations and fetal heart rate to identify tachycardia or hypotension
assess lung sounds
assess for presence of dyspnea or chest pain to indentify pulmonary edema or myocardial ischemia
obtain ordered glucose and potassium levels
have propranolol available
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What is the primary nursing assessment related to this tocolytic drugs
Magnesium sulfate
Observe for urine output of at least 30ml/hr
presence of deep tendon reflexes and respirations of at least 12 breaths per min
Assess heart and lung sounds
observe bowel sounds and assess for constipation
have calcium gluconate avaliible
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What is the primary nursing assessment related to this tocolytic drugs?
Indomethacin
Observe for nausea vomiting and abnormal bleeding
check fundal height
have woman do kick counts to identify fetal movements.
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What is the primary nursing assessment related to this tocolytic drugs?
nifedipine
Teach about flushing of the skin and headache
observe maternal pulse (report if more that 110 bpm) fetal heart rates and maternal blood pressure
warn of postural hypotension and teach to assume a sitting or standing position gradually after lying down
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What is the primary nursing assessment related to this tocolytic drugs?
Corticosteriods
Assess lung sounds
teach woman to report chest pain or heaviness or any difficulty breathing
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What are the two variations of prolapsed cord?
Complete: cord visible at vaginal opening
occult prolapsed cord cannot be seen or felt on vaginal examination but is suspected based on fetal heart rate.
The cord may slip into the vagina where it can be felt as a pulsating mass. It may slip outside the vagina, where it is visable
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What are the two objectives if umbilical cord prolapse occurs or is suspected
Relieve pressure on the cord with position changes increase oxygen delivery to the placenta
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Describe three variations of uterine rupture?
Complete rupture --open communicatoin between the uterine and perioneal cavities
incomplete rupture --rupture into the the peritoneum or broad ligament but not into other peritoneal cavity
Dehiscence--partial separation of a previous uterine scar
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Why may amniotinc fluid embolism result in disseminated intravascular coagulation?
Amniotic fluid is rich in thromboplastin initiating uncontrolled clotting that consumes normal clotting factors
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If a pregnant woman suffers trauma, why should medical and nursing care focus on her stabilization before fetal stabilization.
If the mothers condition deteriorates the fetal condition will inevitabliy deteriorate also because the fetus is totally dependent on the woman for oxygen nutrients and waste removal.
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A woman at 32 weeks of gestation has had a car accident. Her vital signs are stable and the fetal heart rate is 150 to 160 bpm. What should the nurse suspect if the woman uterus seems to be enlarging? What is the correct action?
Despite stable maternal and fetal vital signs an enlarging uterus following trauma suggests possible abruptio placentae
Notify the physician promptly.
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A woman is having hypotonic labor and is very frustrated because this is her third trip to the birth center. What nursing measure is most appropriate for her?
Offer her a warm shower or bath
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A woman has shoulder dystocia when giving birth. THe nurse should expect?
Application of suprapubic pressure
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While in bed a good position for the woman laboring with a twin pregnacy is ?
Side-lying
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WHat is the primary nursing measure to promote fetal descent?
Remind the woman to empty her bladder every 1 to 2 hours
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An infant weighing 8 pounds 10 ounces is born vaginally. Shoulder dystocia occurred at birth. Because of this problem, the nurse should assess the infant for?
Creaking sensation when the clavicals are palpated.
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A woman is fully dilated and the fetal station is 0. The fetus is in a right occiput posterior position. What is the optimal maternal position for pushing>
Squatting
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A woman is having very rapid labor with her 4th child. What nursing measure is most appropriate to help her manage pain?
Coach her to use breathing techniques with each contraction as it occurs.
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Choose the nursing assessment taht most clearly suggests intrauterine infection?
Cloudy amniotic fluid
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A woman telephones the labor unit and says she has been having back discomfort all day. SHe at 32 weeks of gestation. The Nurse should tell the woman that she?
Should come to the hospital for further evaluation.
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A woman is receiving magnesium sulfate to stop preterm labor. The essential nursing assessment related to this drug is?
Hourly vital signs heart sounds and lung sounds
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A few minutes after a womans membranes rupture during labor the fetal heart rate drops from an average of 140 bpm to 75 to 80 bpm. The nurse should immediately
Perform a vaginal examination and palpate for prolapsed cord.
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A woman telephones the labor unit saying that she has recent onset of pain between her shoulder blades thatt is worse when she breathes in. The nurse should
Tell her that she should come to the hospital promptly
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Choose the nursing assessment that most clearly suggests hypovolemia?
Urine output of 20-25 ml/hr
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If contractions are of too long a duration or do not have complete relaxation or uterine tone in between contractions, the adverse effect will be?
Reduce fetal oxygen supply
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A nurse is caring for a client who is in active labor and reports sever back pain during assessment the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to help facilitate normal labor progress?
hands and knees
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A nurse is caring for a client admitted to the labor and delivery unit. With the use of leopold maneuvers it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe?
Prolapsed umbilical cord.
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THe nurse should be aware that which of the following are risk factors for dysfunctional labor?
- Short stature
- cephalopelvic disproportion
- fetal malpresentation
- Maternal fatigue
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A nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse should understand that the fetus s at risk for which of the following?
Meconium aspiration
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A nurse is caring for a client in active labor. When last examined 2 hr ago, the client cervix was 3 cm dilated 100% effaced membranes intact and teh fetus was at a -2 station. the client suddenly states "my water broke". The monitor reveals a FHR of 80-85 /min and the nurse performs a vaginal examination noticing clear fluid and a pulsing loop of umbilical cord in the clients vagina. What should the nurse perform first?
Call for assistance
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What is dysfunctional labor?
one that does not result in normal progress of cervical effacement, dilation and fetal descent.
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What is dystocia?
a general term that describes any difficult labor or birth
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What can a dysfunctional labor result from?
- Problem with powers of labor
- the passanger
- the passage
- the psyche
- or a combination of these.
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What may be needed if a dysfunctional labor does not resolve or if fetal or maternal compromise occurs.
An operative birth (vacuum extractor-or forceps or c-section)
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What may cause problems with the powers?
ineffective contractions
ineffective maternal pushing efforts.
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What are possible causes of ineffective contractions?
maternal fatigue
Maternal inactivity
Fluid and electrolyte imbalance
Hypoglycemia
Excessive analgesia or anesthsia
maternal catecholamines secreted in response to stress or pain
Disproportion between teh maternal pelvis and the fetal presenting part
Uterine overdistention such as with multiple gestation or hyramnios
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WHat is hydramnios?
excess amniotic fluid also called polyhydramnios
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What are two patterns of ineffective uterine contractions?
Hypotonic
Hypertonic
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WHich pattern of ineffective uterine contractions is more common?
hypotonic
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What are hypotonic contractions?
- Coordinated but weak
- become less frequent and shorter in duration
- easily indented at peak
- Woman may have minimal discomfort because the contractions are weak.
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What are hypotonic resting tone?
Not elevated
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What are hypotonic Phase of labor?
- Active typically occurs after 4 cm dilation
- More common that hypertonic dysfunction.
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What are hypotonic therapeutic managment?
Amniotomy ( may increase risk of infection)
Oxytocin augmentation
C-section birth if no progress
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What are hypotonic Nursing care?
- Interventions related to amniotomy and oxytocin augmentation
- Encourage positon changes. an abdominal binder may help direct the fetus toward the mothers pelvis if her abdominal wall is very lax
Ambulation if no contraindication and if acceptable to the woman
Emotional support: Allow her to ventilate feelings of discouragement. Explain measures taken to increase effectiveness of contractions. Include her partner or family in emotional support measures because they may have anxiety that will heighten the woman's anxiety.
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What are hypertonic dysfunction contractions?
- Uncoordinated, irregular
- SHort and poor intensity, but painful and cramplike.
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What are hypertonic dysfunction resting tone?
Higher than normal. Important to distinguish from abruptio placentae, which has similar characteristics
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What are hypertonic dysfunction phase of labor?
- Latent usually occurs before 4 cm dilation
- less common than hypotonic.
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What are hypertonic dysfunction theraputic managment?
Correct cause fi it can be identified
Light sedation to promote rest
Hydration
tocolytics to reduce high uterine tone and
promote placental perfusion.
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What are hypertonic dysfunction nursing care?
Promote uterine blood flow: side lying
promote rest general comfort and relaxation
pain relief
Emotional support: accept the reality of the womans pain and frustration
Reassure her that she is not being childish
explain reason for measures to break abnormal labor patterns and their goal or expected results.
Allow her to ventilate her feeling during and after labor
include partner or family
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why is uterine overdistention associated with hypotonic dysfunction?
because the stretched uterine muscles contracts poorly.
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THe woman who moves about activley typically has a better labor progress than?
one who remains in one positon
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Pain managment techniques such as epidual block may have outcomes that reduce contraction effectiveness, requiring interventions specific to that labor.
Effective pain managment may improver progress of labor, however.
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High resting tone and constant pain are also seen in?
Abruptio placentae
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With hypertonic dysfuntion the mother may become?
- very tired because of long yet nonproductive discomfort.
- She may lose confidence in her ability to cope with labor and give birth
- frustration and anxity further reduce her pain tolerance and interfere with normal processes of labor.
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is oxytocin given with hypertonic dysfunction?
usually not because it can intensify the already high uterine resting tone.
Very low doses of oxytocin however may promote coordination of uterine contractions.
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What do tocolytic drugs do?
inhibit uterine contractions
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Ineffective Maternal Pushing results from?
- –Incorrect
- pushing technique and position
- –Fear
- of injury due to pain and tearing sensation when pushing
- –Analgesia
- or anesthesia effects
- –Psychological
- unreadiness to “let go” of her baby
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What do upright positions such as squatting do?
Add force of gravity to efforts. Semi-sitting and pushing while sitting on the toliet are other options.
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regional analgesia methods may restrict possible maternal positon and may alter?
a woman spontaneous urge to push. Conversly woman who have regional pain management oftern feel an adequate urge to push that is not complicated by excess pain.
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The woman who fears injury because of teh sensation she feels when she pushes may respond to?
Accurate information about the process of fetal descent.
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The woman who is exhausted may push more effectively if ?
She is encouraged to rest until she feel the urge. Encourage her to push with intermittent contractions such as every other contraction also allows her to maintain adequate pushing effort.
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Fetal problems associated with dysfunctional labor are those related to:
Fetal size
fetal presentation or position
multifetal pregnancy
Fetal anomalies
these variations may cause mechanical problems and contribute to ineffective contractions.
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how much does a macrosomia infant weigh?
more than 4000 g (8lbs 13 oz)or 4500 g (9lb 15 oz)
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Distention from a large fetus reduces?
The strength of contractions both during and after birth.
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What is cephalopelvic or fetopelvic disproportion (CPD)?
the head or shoulder may not be able to adapt to the pelvis.
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